Brampton
Brampton
Hospital
Brampton Civic
Civic
HospitalCivic Hospital
905-494-2120
ext. 50801
50801
Phone:
905-494-2120 ext 50086
Fax: 905-494-6758
Etobicoke
Etobicoke General
General Hospital
Hospital
Etobicoke
General Hospital
416-747-3400
ext. 32382
Phone: 416-747-3400 ext 32382
Central
CentralIntake
Intake
Fa
Fax
: 905-494-6758
Fax:
416-747-3399
Referral
Form:
& Palliative
SymptomCare
Management
Clinic (P/PSMC)
Referral Form:
Form: Palliative/Pain
Supportive and
and
Clinic (SPCC)
Referral
Supportive
Palliative Care
Clinic
Criteria
forthe
theSPCC
P/PSMC
includes
pain,
and psychosocial
issues related
torelated
a life-limiting
illness.illness.
Criteria for
includes
pain and
all symptoms,
other symptoms,
as well as, psychosocial
issues
to a life-limiting
Please note that we are NOT a chronic pain clinic and do not manage chronic pain issues.
Consultant/Clinic/Service: ______________________________________________________
Referring Physician/
Referring
Physician: _________________________ Billing Number:
Nurse Practitioner:
______________________
Patient Name: _____________________________ Date of Birth: _______________________
Health Card Number & Version Code: _______________________________________________
Telephone: _____________ Alternative Family Contact #: _____________ Relationship: __________
Address:
_______________________________________________________________
Language: _____________________________ Language Interpreter Required:
Yes
No
Diagnosis & Notes:
__________________________________________________________
Diagnosis/Date
of diagnosis/Notes:
_____________________________________________________________________
One Time Consultation
Follow Up
Palliative Performance Scale: 10-100% (see
reverse)
see below
) PPS:____________ Date:_________________________
REASON FOR REFERRAL
Pain Management
Symptom
Management
Symptom Management
Shortness of Breath
Decision
Making
Decision
Making
Nausea/Vomiting
Anxiety
Psychosocial/Family/Support
Psychosocial
/ Family Support
Fatigue
Anorexia
End of
Life
End
of
LifeCare
Care
Constipation
Other:
Other:
Secretions
Decision Making
Discharge Planning
Psychosocial / Family Support
End of Life Care
Other:
TRIAGE URGENCY: [to be completed by referring physician]
Emergent (< 1 week) e.g., pain or symptom crisis
Urgent (1-2 weeks) e.g., psychosocial crisis; family support; pain/symptom management; transitioning to home care
Non-Urgent (2-4 weeks) e.g., discharge planning; decision making; information/education re: palliative care
Physician Signature: _____________________________________________
Telephone: ____________________________
Date: _______________________
Information for Referring Physician/Practitioner

Referrals must be accompanied by current and pertinent clinical information including consultations, clinical notes,
laboratory and diagnostic information.

Referrals are reviewed and appointments scheduled based on the stated urgency (see below), the Palliative
Performance Scale (see below) and the patient’s residence within the catchment area of the Central West LHIN.

The patient will be seen and assessed by the palliative care physician and members of the team. A care plan will
be developed based on the patient’s current needs. The assessment and recommendations will be reviewed with
the patient and family and provided to the referring physician and primary care physician (if different from the
referring physician).

Follow up care may be designated to the referring physician, the primary care physician or practitioner or the
Palliative Care Clinic. Follow up care may also be shared between the primary care physician or practitioner and
the Palliative Care Clinic. The Palliative Care Clinic does not automatically assume primary care for all referred
patients.
Urgency
Symptoms are best rated using a 10 point scale (0 none-10 worst) i.e. the Edmonton Symptom Assessment Scale.
Emergent (<1 week): Severe symptoms (7 – 10/10), severe psychosocial distress or dysfunction or prognosis < 1 month
Urgent (1-2 weeks): Moderate symptoms (4 – 6/10), moderate psychosocial difficulties or prognosis 1 – 3 months
Non-Urgent (2-4 weeks): No or mild symptoms or prognosis 3 – 12 month
For Office Use Only
Appt Date: ______________ Appt Time: _______________ Date Notified: _______________
Appt given to:
Patient
Other: ________________ By Whom: ________________________
Edmonton Symptom Assessment System:
(revised version) (ESAS-R)
Edmonton Symptom Assessment System:
(revised version) (ESAS-R)
Please circle the number that best describes how you feel NOW:
No Pain
0 1 2 3 4 5 6 7 8 9 10
Worst Possible
Pain
No Tiredness
0 1 2 3 4 5 6 7 8 9 10
Worst Possible
Tiredness
1 2 3 4 5 6 7 8 9 10 Worst Possible
Drowsiness
(Tiredness = lack of energy)
No Drowsiness
0 (Drowsiness = feeling sleepy)
No Nausea
0 1 2 3 4 5 6 7 8 9 10 Worst Possible
Nausea
No Lack of
Appetite
0 1 2 3 4 5 6 7 8 9 10 Worst Possible
Lack of Appetite
No Shortness
of Breath
0 1 2 3 4 5 6 7 8 9 10 Worst Possible
Shortness of Breath
No Depression
0 1 2 3 4 5 6 7 8 9 10 Worst Possible
Depression
1 2 3 4 5 6 7 8 9 10 Worst Possible
Anxiety
1 2 3 4 5 6 7 8 9 10 Worst Possible
Wellbeing
No __________ 0 1 2 3 Other Problem (for example constipation)
4 5 6 7 8 9 10
Worst Possible
_______________
(Depression = feeling sad)
No Anxiety
0 (Anxiety = feeling nervous)
Best Wellbeing
0 (Wellbeing = how you feel overall)
Completed by (check one):
Patient
Family caregiver
Time ______________________
Health care professional caregiver
Caregiver-assisted
Patient’s Name __________________________________________
Date _____________________
BODY DIAGRAM ON REVERSE SIDE
ESAS-r
Revised: November 2010
Please mark on these pictures where it is that you hurt: